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Clínica Universitária de Neurologia Papel da Fibrilhação Auricular no Jovem com Acidente Vascular Isquémico Cláudia Filipa Antunes Pereira Dias Ribeiro Julho’2017

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    Clínica Universitária de Neurologia

    Papel da Fibrilhação Auricular no Jovem com Acidente Vascular Isquémico

    Cláudia Filipa Antunes Pereira Dias Ribeiro

    Julho’2017

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    Clínica Universitária de Neurologia

    Papel da Fibrilhação Auricular no jovem com Acidente Vascular Isquémico

    Cláudia Filipa Antunes Pereira Dias Ribeiro

    Orientado por:

    Prof. Dra. Ana Catarina Fonseca

    Julho’2017

  • 3

    ABSTRACT

    Atrial Fibrillation (AF) is a cause of cardioembolic stroke and therefore an

    important finding in the etiological investigation of ischemic stroke (IS). Currently

    etiological investigation for IS includes the performance of an Electrocardiogram

    (EKG) and a 24hour-EKG monitoring to detect AF in all stroke patients independently

    of their age. However it is known that AF is a disease mainly of older individuals. The

    aim of this work was to study the prevalence of de novo AF as a cause of stroke among

    a sample of Portuguese patients aged 18 to 50 years old admitted to a stroke unit and to

    perform a systematic literature review and meta-analysis to estimate the prevalence of

    atrial fibrillation as a cause of stroke in young stroke patients.

    We did a single-centre observational retrospective analysis. All the data was

    collected from the database of the department of neurology of the Hospital de Santa

    Maria (HSM) from 1st January of 2013 until 31

    st December of 2015. We found a zero

    prevalence of AF 0,015% 95 Confidence Interval (CI) (0,00 – 0,055%) . In the meta-

    analysis we found a pooled prevalence of atrial fibrillation as a cause of stroke in young

    adults of 0.034% 95 CI (0.022-0.045) These findings are important to reconsider the

    performance of a 24-h EKG in all young patients.

    Key Words: Young; Fibrillation; Cryptogenic Stroke; Holter monitoring,

    The present dissertation is based on the author´s opinion and not the FML´s.

    RESUMO

    A Fibrilhação Auricular (FA) é uma causa cardíaca de acidente vascular e

    consequentemente um achado importante na investigação etiológica de acidente

    vascular isquémico (AVCI). A investigação da etiologia do AVCI inclui a realização de

    um eletrocardiograma (ECG) e uma monitorização electrocardiografica cardiaca de

    24horas para deteção de FA em todos os doentes, independentemente da sua idade.

    Contudo, é sabido que a FA é uma doença mais prevalente em indivíduos com mais de

    cinquenta anos. O objetivo deste trabalho foi estudar a prevalência de FA, como uma

    causa de AVC, numa amostra da população Portuguesa, com idades entre os 18 a 50

    anos, admitidos numa unidade de AVC, e, realizar uma revisão sistemática e meta-

    análise para determinar a prevalência da FA como causa de AVC isquémico nos doentes

    jovens.

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    Realizámos uma análise observacional retrospetiva de centro-único. Todos os

    dados foram recolhidos da base de dados do departamento de neurologia do Hospital de

    Santa Maria (HSM) desde 1 de Janeiro de 2013 até 31 de Dezembro de 2015.

    A prevalência de FA encontrada, foi de zero, com um intervalo de confiança

    entre 0 e 0.055%. Na nossa meta-análise encontrou uma prevalência da FA, como causa

    de AVCI nos jovens adultos de 0 e 0.055%. A meta-analise, revelou uma prevalência

    agrupada de FA como causa de AVC, nos adultos jovens, de 0.034% 95CI (0.022-

    0.045) Estes achados são importantes, para que se reconsidere a necessidade de realizar

    24h-ECG em todos os doentes jovens.

    Palavras-chave: jovens; Fibrilhação; AVC indeterminado; Holter.

    O trabalho final exprime a opinião do autor e não da FML.

  • 5

    INDEX

    Abstract / Resumo ............................................................................................................. 1

    Introduction ...................................................................................................................... 4

    Subject and Methods ........................................................................................................ 6

    Results ............................................................................................................................. 8

    Discussion ......................................................................................................................... 8

    Conclusion ..................................................................................................................... .10

    Acknowledgments ........................................................................................................... 11

    Bibliography ................................................................................................................... 12

    Anexes ............................................................................................................................ 16

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    INTRODUCTION

    Stroke is a cause of high morbidity and mortality worldwide1. Finding a cause of

    stroke is a daily challenge to the trained neurologist, who has to treat young adults with

    ischemic stroke.2

    Causes of stroke in young adults differ from the ones found in older patients.

    Young adults tend to have more frequently etiologies such as: arterial dissections,

    cardioembolism related to Patent Foramen Ovale; vasculitis or hematologic disorders3.

    In older patients the main causes of ischemic stroke are atrial fibrillation or large vessel

    disease. Young adults tend to have a lower frequency of conventional cardiovascular

    risk factors (i.e. hypertension, dyslipidaemia, diabetes mellitus) than older patients 45

    that partly explains the different etiologies that may be found.

    Atrial Fibrillation is a common sustained arrhythmia with an estimated

    prevalence of six million in Europe and these numbers are expected to double in the

    next 50 years. It confers a 5 fold increase risk of stroke, being responsible for one in

    five ischaemic strokes, which are often fatal. Those patients who survive are left more

    disabled and more likely to suffer a recurrence of their stroke, when compared to other

    causes of stroke, and its likelihood increases with age. AF is defined as a cardiac

    arrhythmia with the following characteristics:

    The surface EKG shows ‘absolutely’ irregular RR intervals;

    There are no distinct P waves on the surface EKG. Some apparently regular

    atrial electrical activity may be seen in some EKG leads, most often in lead

    V1.

    The atrial cycle length (when visible) is usually variable and 200 ms (300

    bpm).

    Clinically, we can distinguish five types of AF based on the presentation and

    duration of the arrhythmia: first diagnosed, paroxysmal, persistent, long-standing

    persistent, and permanent AF.

    1. First diagnosed - Every patient who presents with AF for the first time,

    irrespective of the duration of the arrhythmia or the presence and severity of

    AF-related symptoms.

    2. Paroxysmal AF - is self-terminating, usually within 48h. Although AF

    paroxysms may continue for up to 7 days, the 48h time point is clinically

    important, because after this the likelihood of spontaneous conversion is low.

  • 7

    3. Persistent AF - when an AF episode either lasts longer than 7 days or requires

    termination by cardioversion.

    4. Long-standing persistent AF - AF lasted for ≥1 year when it is decided to

    adopt a rhythm control strategy.

    5. Permanent AF - when the presence of the arrhythmia is accepted by the patient

    (and physician). 13

    Atrial Fibrillation occurs due to abnormalities in the atrial tissue. This can be

    structural in the setting of underlying heart disease associated with: hypertension,

    coronary artery disease, valvular heart disease. Atrial tissue promotes abnormal impulse

    formation and/or propagation. In AF, ischaemic stroke and systemic arterial embolism

    are generally explained with thrombus originating from left atrial appendage. 11

    AF

    affects calcium homeostasis. With an alteration in the physiologic calcium homeostasis,

    AF induces further electrophysiological changes in the atria. This process leads to

    shortening of the atrial effective refractory period, as well as atrial dilation, stretch and

    fibrosis.12

    In one third of young adults who suffer an ischemic stroke (IS) the cause is

    unknown 14

    . Both, the European Stroke organization and the American Heart

    Association/ American Stroke Association guidelines, suggest performing an EKG and

    at least a 24 hours Holter monitoring (24h-HM), or continuous monitoring, to detect AF

    on all patients; and on a selected number of patients, who presents with IS15

    ,16

    . Several

    studies report the benefit of using Holter Monitoring (HM) in order to detect

    AF.17

    ,7,18

    ,19

    ,20

    ,21

    ,22

    ,23

    ,24

    ,25

    ,26

    Most of the analysed data shows a low prevalence of atrial

    fibrillation in young adults.. 6,7,8,9. The FAMA study (a cross-sectional study of a

    representative sample of the Portuguese population aged 40 and over, resident in

    Portugal, which aimed to determine the prevalence and incidence of AF), reports a

    prevalence of 0,2% of AF in patients under 50 years old, with a total prevalence of

    2,5%.10

    In this paper we aim to analyse the prevalence of de novo AF in young stroke

    patients as a cause of Cryptogenic Ischemic Stroke (CIS).

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    SUBJECTS AND METHODS

    In order to determine the prevalence of atrial fibrillation as a cause of stroke

    among young adults we performed a systematic review of the literature and a

    retrospective analysis, of a case series of patients, admitted to the stroke unit of a

    university hospital.

    PUBMED was systematically searched using the following keywords: stroke

    AND young AND (atrial fibrillation [Mesh] OR Holter OR electrocardiogram OR

    arrhythmia). We selected studies, from 1998 until 2015 (last search was made on 1st

    January 2016), performed on subjects aged under 50 years old with an acute brain

    infarction from cryptogenic origin (to whom an EKG was performed). Articles had to

    be written in English, Portuguese, Spanish, Italian or French language. We excluded

    case-controls, author´s opinion, case-reports, clinical comments, letters, and editorials.

    The following data was recorded in each study: Total number of young stroke patients

    included; Percentage of patients studied with EKG and 24 hours Holter monitoring

    (24h-HM).

    This systematic review followed by the Meta-analysis of Observational Studies

    in Epidemiology guidelines for reporting Meta-Analyses and Systematic Reviews of

    Observational Studies.

    This is a single-centre observational retrospective analysis, taken place at

    Hospital of Santa Maria, department of Neurology, Lisbon (Portugal). Hospital de Santa

    Maria is a tertiary stroke centre in Portugal, which serves directly a population of

    372831, although this number may be underestimated, because patients from primary or

    secondary Hospitals can be transferred to here.

    We analysed data collected into the Hospital´s database from patients with an

    acute IS aged between 18 and 50 years old, admitted from the Emergency Room (ER)

    to the Neurology department (ND) from 1st January 2013 to 31

    st December 2015.

    In the ER all patients underwent a 1) Brain CT; 2) serial laboratory samples

    containing: hematologic evaluation; biochemistry; syphilis serology; auto-antibodies

    searched on plasma; pro-thrombotic states; urinalysis 3) admission ECG; in the ND: 1)

    Ultrasound of cervical and cerebral arteries within the first 72 h; 2) Transthoracic

    echocardiography (TTE) or Transesophageal echocardiography (TEE) 3) 24-HM; 4)

    Repeating CT after 24h from the first or, in selected cases, MRI.

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    All the exams were analysed by a trained neurologist exception made for the

    24h-HM which were reviewed by a cardiologist. Thus IS was diagnosed based on the

    CT performed on patients presenting with clinical signs and symptoms of an acute IS

    which showed an ischemic brain lesion corresponding to the patient’s symptoms (figure

    2).

    CIS was defined following the Trial of Org 10172 in Acute Stroke Treatment

    (TOAST) classification 27

    . We defined AF as an irregular ventricular response in the

    absence of P-waves, for at least a period of 30 s duration, without a pattern more

    consistent with an alternative diagnosis18

    .

    We included in this study: patients aged between 18 years old and 50 years old

    with an acute brain infarction from cryptogenic origin. Exclusion criteria were not

    having: an admission EKG, a 24h-HM and a TTE or TEE after the diagnose of CIS.

    Stroke severity was evaluated by an accredited neurologist using the National

    Institute of Health Stroke Scale (NIHSS).

    Data analysis

    Data analysis was performed with IBM SPSS Statistics 21 program for

    Microsoft Windows. Continuous variables are described by mean Standard Deviation

    SD or median [interquartile range (IQR)]. Categorical variables are described by

    percentages and absolute numbers. The given confidence intervals (CI) are of ninety-

    five for the prevalence of AF. Univariate analysis was performed with the chi-squared

    test or Fisher’s exact test for dichotomous variables. Continuous variables were

    analyzed with the t-test or the Mann–Whitney test when appropriate. Values of P < 0.05

    were considered significant.

    We used Meta-Analyst17

    (Center for Evidence-based Medicine, Brown

    University School of Public Health, Providence, United States) software for statistical

    analysis and to derive forest plots presenting the results of individual studies and pooled

    analysis.

    Ethic

    This study was approved by the Santa Maria Hospital’s Ethics Committee.

    http://topics.sciencedirect.com/topics/page/Evidence-based_medicine

  • 10

    RESULTS

    Observational Study

    Among 102 patients diagnosed with ischemic stroke, only 33 had an unknown

    cause for their stroke and met the inclusion criteria (Table 2), with a median age of 46

    years old (the younger was 18 years old and the older 50 years old), the median

    admittance National Institutes of Health Stroke Scale (NIHSS) score was 3 and median

    discharge RANKIN was 1. The highest incidence rate of CIS was among men (54,5%)

    compared to women (45,5%). Baseline characteristics of these patients are presented in

    table 3

    AF was not diagnosed in any patient (Figure 2).

    Meta-analysis

    We found 235 studies. In the end 19 studies were eligible for the predetermined

    criteria (Table 1 and figure 3).

    The proportion of AF in young patients presenting with ischemic stroke, from

    cryptogenic origin, was 0.034% 95CI (0.022-0.045) as exhibited in figure 1. There was

    a significant heterogeneity among the pooled studies (I 2>50%).

    DISCUSSION

    The prevalence of AF found in young adults as a cause of cryptogenic stroke

    was very low, which is consistent with the literature. According to the FAMA study10

    the prevalence of AF increases with age, being higher among elderly Portuguese people.

    AF occurs due to abnormalities in the atrial tissue, in the setting of underlying

    heart disease. 11

    AF affects calcium homeostasis by inducing further

    electrophysiological and structural changes in the atria.12

    This might explain why age is

    a risk factor for AF, as shown in literature. 4,

    28,

    21,

    29 This was a retrospective study

    using a small pool of patients; it is not possible to draw conclusions about all the

    Portuguese habitants.

    This is one of a few studies that specifically analysed the prevalence of AF in

    young stroke patients, up to 50 years old, due to an intensive search for this arrhythmia.

  • 11

    The majority of analysed data from different studies revealed a lack on HM in

    all patients reported as having IS of unknown origin, this may therefore underestimate

    the true prevalence of atrial fibrillation as not all patients were submitted to this exam.

    The bulk of studies reported a frequency of AF up to 5% (table 1) in this

    population. Except for a few studies, which were the great contributors for the

    heterogeneity found in the present meta-analysis (figure 1). The biggest result disparity

    was reported by Ghandehari K et al. 30

    , who found a prevalence of AF in 23% of IS

    patients aged 15-45 years old, this was due to the reported cases being related with

    rheumatic valvular disease, an uncommon finding among the studied populations by the

    other studies´ authors. Daniel Šaňák et. al. 31

    showed a low frequency of AF on 24h-HM

    and on a prolonged EKG-HM (up to 7 days), however they reported an increased

    prevalence of AF (9,5% in the ischemic stroke patients aged up to 50 years old) for the

    reason that they prolonged the investigations of AF using an HM up to 3 weeks. D.

    Prefasi et al.17

    reported AF as an independent factor of stroke severity in patients aged

    up to 50 years old who suffered from an IS, and showed a prevalence of 8,9%, in their

    population, most of AF was previously known, and not a de novo finding.

    Few studies described in detail the search of AF in young stroke patients, and

    only ours and Daniel Šaňák´s et. al. 31

    performed a 24h-HM to all the included subjects.

    After a careful analysis of the data from the literature, the great majority of the

    studies showed a low prevalence of FA among the CIS patients. Since the meta-analysis

    shows a low overall prevalence we suggest to review the current indication to perform a

    continuous EKG HM in all patients under 50 years old presenting with a stroke of

    unknown origin, because AF is a rare diagnosis. Instead, an EKG could be used as an

    exclusion diagnostic tool of AF due to its simplicity and cheapness. It would be

    important to study the economic impact on the use of a long-term EKG-HM in this

    specific population, which might show an urge to revise the recommended guidelines

    since they are directed to the general population, not taken in consideration the

    specificities of the younger.

  • 12

    CONCLUSION

    The meta-analysis showed a pooled prevalence of atrial fibrillation as a cause of

    stroke in young adults of 0.034% 95CI (0.022-0.045). These findings are important to

    reconsider the performance of a 24-h EKG in all young stroke patients.

  • 13

    ACKNOWLEDGMENTS

    Firstly, I would like to express my sincere gratitude to my advisor Professor

    Doctor Ana Catarina Fonseca for her hard work, patience, motivation, and immense

    knowledge. I have to express my gratitude for her continuous support and guidance,

    without her I would not be able to accomplish my goal, since she helped me in all the

    time of research and writing. My sincere thanks also goes to my friends and family, who

    gave me support and motivation to go forward with my ideas and keep up with my

    work.

  • 14

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  • 18

    ANEXES

  • TABLES

  • 20

    Table 1 AF detection in ischemic stroke patients from clinical studies′ data

    Abbreviations: AF: Atrial Fibrilation; HM: Holter Monitoring; NP: Not Performed;

    NR: No reference

    Study N Age HM Yield of HM

    to detect AF AF detected

    Ribeiro 33 18-50 100% 0% 0%

    D. Prefasi et al.17

    157 15-50 24.8% 7.7% 8.9%

    Daniel Šaňák et. al. 31

    95 ≤50 100% 7.6% 9.5%

    A. W. M. Janssen et. al.4 49

  • 21

    Table 2 Investigations

    Total Ischemic Stroke Patients from

    1/1/2013 until 31/12/2015, aged 18-50

    years old

    102

    Total Cryptogenic stroke Patients met the

    inclusion Criteria

    33

  • 22

    Table 3 Baseline characteristics

    Baseline

    characteristics Total: 33 patients

    Age 46 (Median)

    Sex 45.5% (Female)

    54.5% (Male)

    Admitance NIHSS 3 (Median)

    Discharge RANKIN 1(Median)

    Hipertension 42.4% (Frequency: 14)

    Diabetes Mellitus 12.1% (Frequency: 4)

    Smoker 36.4% (Frequency: 12)

    Coronary disease 3% (Frequency: 1)

    Dyslipidemia 75.8% (Frequency: 25)

  • 23

    FIGURES

  • 24

    Figure 1 Forest Plot of Atrial Fibrillation as a cause of cryptogenic stroke in young

    adults. The marker size represents the weight of the study.

  • 25

    IS n=102

    History PE Lab. ECG Brain CT US TTE/TEE

    CIS n=33

    HM

    AF n=0

    Abbreviations: AF: Atrial Fibrillation CIS: Cryptogenic Ischemic Stroke; CT:

    Computed Tomography, which was repeated after 24h from the first; ECG:

    Electrocardiogram; HM: 24 hour - Holter Monitoring; IS: Ischemic Stroke; Lab:

    laboratory samples containing: hematologic evaluation; biochemistry; syphilis serology;

    auto-antibodies searched on plasma; pro-thrombotic states; urinalysis MRI: Magnetic

    Resonance Imaging, repeated after 24h from the first CT in selected cases; PE: Physical

    Examination; TEE: Transesophageal echocardiography; TTE: Transthoracic

    echocardiography; US: Ultrasound of cervical and cerebral arteries within first 72 h;

    102: number of patients diagnosed with Ischemic stroke based on clinical signs and

    symptoms with a corresponding brain lesion on CT or MRI; 33: number of patients

    diagnosed with Cryptogenic Ischemic Stroke following the orientation of the Trial of

    Org 10172 in Acute Stroke Treatment; O: Number of patients detected with Atrial

    Fibrillation after analysing the ECG and 24h-HM

    Figure 2 Flow Chart of diagnostic testing for Atrial Fibrillation as a source of cryptogenic

    Ischemic stroke in patients aged 18 to 50 years old

  • 26

    Figure 3: Flow Chart of the study selection

    Abbreviations: N – Number of studies; Keywords: stroke AND young AND (atrial

    fibrillation [Mesh] OR Holter OR electrocardiogram OR arrhythmia)

    PUBMED SEARCH using the key words

    • N = 235

    Did not met the inclusion criteria

    • N = 216

    Met the inclusion criteria

    • N = 19

  • 27

    RESUMO

    A Fibrilhação Auricular (FA) é uma causa de acidente vascular cerebral (AVC)

    é um achado etiológico importante na investigação da causa de acidente vascular

    cerebral isquémico (AVCI). A investigação da etiologia do AVCI inclui a realização de

    um eletrocardiograma (ECG) e uma monitorização de 24hora-ECG para deteção de FA

    em todos os pacientes, independentemente da sua idade. A FA é uma doença mais

    prevalente em idosos. O objetivo deste trabalho foi estudar a prevalência de FA, como

    uma causa de AVC, numa amostra da população Portuguesa, com idades entre os 18 a

    50 anos, admitidos numa unidade de AVC, e, realizar uma revisão sistemática para

    estimar a prevalência da FA como causa de AVC nos pacientes jovens.

    Realizámos uma análise observacional retrospetiva de centro-único. Todos os

    dados foram recolhidos da base de dados do departamento de neurologia do Hospital de

    Santa Maria (HSM) desde 1 de Janeiro de 2013 até 31 de Dezembro de 2015.

    A prevalência, de FA, encontrada, foi de zero, com um intervalo de confiança

    entre 0 e 0,055. Na nossa meta-análise encontrámos uma prevalência da FA, como

    causa de AVCI nos jovens adultos de 23% a 0%, com a maioria dos estudos a reportar

    uma prevalência inferior a 5%. Estes achados são importantes, para que se repense no

    uso 24h-ECG em todos os pacientes jovens.

    Palavras-chave: jovens; Fibrilhação; AVC indeterminado; Holter.

    O trabalho final exprime a opinião do autor e não da FML.

  • 28

    Índice

    Resumo ........................................................................................................................... 27

    Introdução ....................................................................................................................... 29

    Sujeitos e Métodos ......................................................................................................... 29

    Análise de resultados ...................................................................................................... 30

    Resultados ....................................................................................................................... 30

    Discussão ........................................................................................................................ 31

    Conclusão ....................................................................................................................... 31

    Bibliografia ..................................................................................................................... 32

    ANEXOS ........................................................................................................................ 35

  • 29

    INTRODUÇÃO

    O AVC é uma causa de morbimortalidade a nível mundial.1 Os jovens tendem a

    ter uma menor frequência dos fatores de risco convencionais, diferente dos encontrados

    nos mais idosos. Nos doentes com mais de 50 anos de idade, as causas major de AVC

    são Fibrilhação Auricular (FA) e doença dos grandes vasos.2,3 Nos mais jovens, a

    maioria das causas reportadas são disseção arterial, patência do foramen ovale.4 Um

    terço dos jovens, que se apresentam com AVCI, a causa permanece indeterminada.5

    Dados do estudo FAMA, realizado na população Portuguesa, sugerem que a FA

    como causa de AVC criptogénico (AVCC) em doentes abaixo dos 50 anos de idade tem

    uma prevalência de 0,2% 6. Apesar disto, a FA é uma arritmia comum, com uma

    prevalência estimada de seis milhões na Europa, aumentando em 5 vezes o risco de

    AVC e é responsável por um em cinco AVCI, sendo geralmente fatais, e, os

    sobreviventes têm mais sequelas e com maior risco de desenvolver novo AVC. A

    probabilidade de ter FA aumenta com a idade.7

    Tanto a Organização Europeia como a American Heart Association /American

    Stroke Association, nas suas guidelines, recomendam a realização de um ECG e pelo

    menos uma monitorização Holter das 24h (24h-HM) ou monitorização cardíaca

    continua, para detetar FA, nos doentes que se apresentem com AVCI.8,9

    Uma vez que só existe um estudo à cerca deste assunto em Portugal, a nossa

    hipótese é que a FA de novo, detetada por 24h-HM é menos frequente que o esperado,

    nos doentes jovens com AVCC. O objectivo deste trabalho é analisar a prevalência de

    FA nos jovens com idades entre 18 e 50 anos de idade.

    SUJEITOS E MÉTODOS

    Para o teste da nossa hipótese foi feito um estudo observacional

    retrospectivo de centro único. Analisaram-se os dados de uma série de doentes

    admitidos na unidade de AVC do Hospital de Santa Maria (Hospital terciário, servindo

    directamente uma população de mais que 372831 doentes); e, uma revisão sistemática

    da literatura, usando as palavras de pesquisa: “stroke AND young AND (atrial

    fibrillation [Mesh] or Holter OR electrocardiograma OR arrythmia);

    Selecionaram-se estudos desde 1998 até 2015 (última pesquisa realizada a 1 de

    Janeiro de 2016).

    Os Critérios de inclusão foram:

  • 30

    Estudos observacionais em sujeitos com idades inferiores a 50 anos com

    AVCC, nos quais foi realizado um ECG.

    Artigos escritos nas línguas: Portuguesa, Inglesa, Francesa, Espanhola;

    Italiana.

    Os critérios de exclusão foram:

    Caso-controlo; Opinião de autor; Estudos de caso; experiências clínicas;

    comentários clínicos; cartas; notícias do editor.

    Para a realização do estudo observacional, foram analisados dados da base do

    Departamento de Neurologia do Hospital de Santa Maria (Lisboa). Incluíram-se doentes

    entre os 18 e 50 anos, admitidos na Urgência para o Departamento de Neurologia desde

    1 de Janeiro a 31 de Dezembro de 2015, com AVCC, aos quais foi realizado, pelo

    menos um 24h-HM para detetar FA. A figura 2 mostra a marcha diagnostica.

    AVCC foi definido pelo Trial of Org 10172 no Tratamento Agudo do AVC

    (TOAST) e a gravidade do AVC avaliada pela Escala do Instituto de saúde de AVC

    (NIHSS).

    O presente estudo foi aprovado pelo Comité de Ética do Hospital de Santa Maria.

    ANÁLISE DE RESULTADOS

    Os dados foram tratados usando o programa IBM SPSS Statistics 21 para

    Microsoft Windows, consideraram-se como estatisticamente significativos, os valores

    de P < 0.05. Para a meta-análise usou-se o programa Meta-Analyst, todas as estimativas,

    foram consideradas estatisticamente diferentes quando P < 0.05.

    RESULTADOS

    Estudo observacional

    De uma base de 102 doentes, apenas 33 cumpriram os critérios de inclusão

    (tabela 2), com uma idade média de 46 anos, e média NIHSS de 3, nenhum apresentou

    FA. A incidência de AVCC foi detetada nos homens (54,5%). Características iniciais

    dos doentes estão representadas na tabela 3.

    Meta-analise

    Dos 235 artigos encontrados, apenas 19 foram elegíveis (tabela 1 e figura 3).

    Tendo-se verificada uma proporção de 0,034% 95 Intervalo de Confiança (IC) (0,022 –

  • 31

    0,045) como demonstrado na figura 1. Com uma heterogeneidade significativa entre os

    estudos (I2 superior a 50%)

    DISCUSSÃO

    Foi encontrada uma baixa prevalência de FA na maioria dos estudos, indo de

    encontro aos nossos resultados.

    A maioria dos estudos reporta uma prevalência de FA de até 5% (tabela 1) Com

    exceção de alguns estudos, que contribuem para a heterogeneidade dos resultados

    obtidos pela meta-analise.

    CONCLUSÃO

    Dada a baixa prevalência de FA como causa de AVCI nos jovens, propomos

    uma revisão das indicações para o uso indiscriminado de 24h-HM.

  • 32

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  • 35

    ANEXOS

  • 36

    TABELAS

  • 37

    Tabela 1 FA detetada na bibliografia, em doentes com AVCI

    Abbreviations: FA: Fibrilhação Auricular; HM: Monitorização Holter ; NE: Não

    Efetuado; SR: Sem referencia

    Tabela 2 Investigações

    Total de doentes com AVCI de 1/1/2013

    até 31/12/2015, com idades de 18-50 anos

    102

    Total de doentes com AVCC que

    cumpriram os critérios de inclusão.

    33

    Study N Idade HM

    Realização

    de HM para

    detetar FA

    FA detada

    Ribeiro 33 18-50 100% 0% 0%

    D. Prefasi et al.10

    157 15-50 24.8% 7.7% 8.9%

    Daniel Šaňák et. al. 11

    95 ≤50 100% 7.6% 9.5%

    A. W. M. Janssen et. al.3 49

  • 38

  • 39

    Tabla 3 Características Basais

    Características

    Basais Total: 33 patientes

    Idade 46 (Media)

    Sexo 45,5% (Mulher)

    54,5% (Homem)

    NIHSS à admissão 3 (Media)

    RANKIN na alta 1(Media)

    Hipertensão 42,4% (Frequência: 14)

    Diabetes Mellitus 12,1% (Frequência: 4)

    Fumador 36,4% (Frequência: 12)

    Doença Coronária 3% (Frequência: 1)

    Dislipidémia 75,8% (Frequência: 25)

  • 40

    FIGURAS

  • 41

    Figura 3 Forest Plot da Fibrilhação auricular como causa de AVCC em adultos jovens .

    O tamanho da marca, representa a prevalência agrupada do estudo.

  • 42

    AVCI n=102

    Historia EF Lab. ECG TC

    cerebral US

    Repeat TC / RM

    CIS n=33

    TTE TEE HM

    FA n=0

    Abreviaturas: AVCI: Acidente vascular isquémico. CIS: Acidente vascular

    isquémico de origem criptogénica. ECG: Electrocardiogram. EF: Exame Físico. ETE:

    Ecocardiografia transesofágica. ETT: Ecocardiografia Transtoracica. FA: Fibrilhação

    Auricular. HM: Monitorizaçã Holter das 24h. Lab: Análises de sangue: avaliação

    hematológica; bioquímica; serologias para sífilis; auto-anticorpos; estados

    protromboticos; análise de urina. MRI: Magnetic Resonance Imaging, repeated after 24h

    from the first CT in selected cases. TC: Tomografia Computorizada, a qual foi repetida

    depois de 24h da primeira. US: Ecografia das arterias cerebrais e arteriais nas primeiras

    72 horas. 102: numero de pacientes com diagnostic de AVC Isquémico com base nos

    sinais e sintomas clínicos, com uma lesão cerebral correspondente na TC ou RM. 33:

    numero de pacientes diagnosticados com CIS de acordo com as orientações do Trial of

    Org 10172 in Acute Stroke Treatment. O: Numero de pacientes com FA, após a análise

    de ECH e do 24h-HM.

    Figura 4 Realização de Testes diagnostic para a Fibrilhação auricular, como fonte de

    Acidente Vascular Cerebral Isquémco de origem Criptogénica em jovens adultos, com

    idades entre 18 e 50 anos.